Communicating Via Documentation

To continue on from Part 7: I’ve noticed that many counselors, even experienced ones, struggle to make effective use of the SOAP or DAP format required by their employers. I wanted to take a few moments to clarify things.

The SOAP note was initially used by physicians in the medical record, to make brief but helpful updates on patient progress from office visit to office visit. In its original form, the note worked something like this:

Subjective: This was ordinarily a complaint reported by the patient. As in ‘my back hurts’, or ‘I can’t sleep’, or ‘I fell and hurt my knee.’

Objective: Something the doctor did to measure or observe what was wrong with the patient. Take vital signs, for instance, or examine a wound, or check lab results. In physical medicine, this is according to established procedures, often with an eye to confirming a diagnosis.

Assessment: The physician’s opinion about the patient’s problem– its possible cause, or likely outcome– based on the subjective and objective data.

Plan: What the doctor intended to do (if anything) to remedy the problem.

This sounds like a fairly straightforward process, but things get a lot more complicated when you’re dealing with complex problems, particularly of the sort found in behavioral health clinics. It’s sometimes difficult to compartmentalize things into the discrete components required by this format.

One solution is to select one or two aspects of particular importance and focus on those. Another is to look at more aspects but provide less specific information about each.

Two examples: client Bob, who has until recently been dependent on illicit drugs, proclaims during group that that he’s drug-free when in fact you have sitting on your desk a report from a random drug test suggesting he hasn’t been. Here’s one way to document that.

S: “I’m proud to say I’ve been completely drug-free for a whole month, the first time for me in two years.”

O: Client’s random test on 6-10-15 came back positive for cocaine and marijuana.

A: Conflicting report from lab casts doubt on client self-report, as well as progress.

Seem logical? The best way we’ve found to teach clarity in documentation (and that’s really the goal) is to use real-life examples and ask the group for feedback on the quality of each student’s progress note. Is it clear? Easy to follow? Thorough, in the sense that it addresses all the necessary elements without unnecessary complication?

It takes a little practice, but it’s worth the effort. And it’s like riding a bike.